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FEDEX FLIGHT 1478

  • More Research Into The Effects of Fatigue
  • Shorter Duty Day
  • "Black Hole Illusion" Recurrency Training
  • More ADM Training for ALL Flight Crew
  • Continue On Briefed Approach
  • Go Around, Go Around, Go Around!

Crew Recommendations

Jenna Glasa & Bret Louderback

Injuries To Flight Crew

  • All Three Crew Members Seriously Injured
  • NTSB Report Only Contains First Officer's

Hospitalization Record

  • Severe Chest Injuries
  • Hypoxemia
  • Right Lower Lobe Lung Consolidation
  • Breathing Rate Upon Arrival: 16 BPM

BIBLIOGRAPHY

  • http://www.ntsb.gov/doclib/reports/2004/AAR0402.pdf
  • http://www.airdisaster.com/photos/fdx1478/photo.shtml
  • http://www2.airliners.net/aviation-forums/general_aviation/read.main/1002974/

SUMMARY OF DAMAGE

Crew

Captain

  • Age: 55 Years Old
  • Hours: Approximately 13,000-14,000
  • 727 PIC - 861 Hours
  • Years with FedEx: 13 Years
  • Ratings: ATP w/Multi-Engine Land

Type Rating in 727, CE-500, CL-600

Crew (Continued)

First Officer

  • Age: 44 Years Old
  • Hours: Approximately 7,500 - 8,500 Hours
  • Years with FedEx: 4.5 Years

Crew (Continued)

Flight Engineer

  • Age: 33 Years Old
  • Hours: 2,600 Hours
  • Time With FedEx: 10 Months

QUESTIONS?

Accident Facts

Glide Path

  • All Pilots Recall Seeing Normal Glidepath
  • "Normal Flight Until Last Few Seconds"
  • NTSB proved ALL RED for 42 seconds

Cockpit Voice Recorder

Damages To Airframe

  • Airframe was completely destroyed
  • Caused Initially By Crash
  • Post Crash Fuel Fire

General Information

  • Date: 26 JUL 2002
  • FedEx Flight 1478
  • Departure Airport: KMEM (Memphis)
  • Arrival Airport: KTLH (Tallahassee)
  • Boeing 727-232F
  • N497FE

Damage To Airport

  • Minor Damage To Airport Property
  • Main Damage To Airport Was Downed

Trees

  • Fire Burned 1000' From Runway
  • Damage Mainly Aesthetically Unpleasant

NTSB Findings

  • Cause of Accident Was Human Error
  • Pilots Out of Currency for Black Hole Training
  • FO's Color Vision Test Not Adequate
  • Fatigue Was A Contributing Factor
  • Failure to Establish Proper Glidepath

Overview

  • General Information
  • Crew
  • Aircraft
  • Accident Facts
  • CVR
  • Damages
  • NTSB Findings
  • Recommendations
  • Previous recommendations about fatigue
  • Previous recommendations about CFIT
  • Recommended continued research on color vision deficiency tests
  • Especially for glideslope, light gun signals, emergency situations, etc.

NTSB Recommendations

Aircraft

  • Manufacture Date: September 1974 (Purchased from Delta Airlines in 1990)
  • Engines: 2 P&W JT8D-15

1 P&W JT8D-15A

  • Hours: 37,980
  • Captain: Flight time: 1:23, Duty time: 2:35
  • Stayed Up Night Prior Taking Care of Sick Dog
  • First Officer: Flight time: 4:02, Duty time: 10:29
  • Flight Engineer: Flight time: 3:43, Duty time: 10:41
  • All three members had different flight, duty and sleep schedules prior to the accident

Fatigue

Accident Facts

  • First Time All Three Crew Flew Together
  • Captain and FE Flew Together Before
  • During Descent Brief, FE Briefed Moderate CFIT Risk at KTLH

Crew Resource Management

Accident Facts

WEATHER

  • Night VFR Conditions
  • IFR Flight Plan
  • Weather Information Before Accident
  • Wind: 120 @ 5 Knots
  • Visibility: 9 Statute Miles
  • Clouds: Few at 100; SCT 18,000; SCT 25000

Precision v.s. Non-Precision

  • Originally Chose Visual RWY 27
  • Backed Up With ILS RWY 27
  • Captain Changed Plan for Visual RWY 9
  • No Glideslope on RWY 9, but had PAPI
  • Confusion In Cockpit Until Turning Final
  • No Callouts On Final
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